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Amitriptyline Is Readily Absorbed from the Gastrointestinal Tract, Peak Plasma Concentrations Occurring Within About 6 Hours After Oral Doses

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Amitriptyline Is Readily Absorbed from the Gastrointestinal Tract, Peak Plasma Concentrations Occurring Within About 6 Hours After Oral Doses ______________________________________________________________________________________________________________ Composition: Each Tablet Contains Amitriptyline 5/ 10 / 25 mg Mecobalamin SR 1500 mcg Pharmacokinetic properties: Amitriptyline is readily absorbed from the gastrointestinal tract, peak plasma concentrations occurring within about 6 hours after oral doses. Amitriptyline undergoes extensive first-pass metabolism and is demethylated in the liver by the cytochrome P450 isoenzymes CYP3A4, CYP2C9, and CYP2D6 to its primary active metabolite, nortriptyline. Other paths of metabolism of amitriptyline include hydroxylation (possibly to active metabolites) by CYP2D6 and N-oxidation; nortriptyline follows similar paths. Amitriptyline is excreted in the urine, mainly in the form of its metabolites, either free or in conjugated form. Amitriptyline and nortriptyline are widely distributed throughout the body and are extensively bound to plasma and tissue protein. Amitriptyline has been estimated to have an elimination half-life ranging from about 9 to 25 hours, which may be considerably extended in overdosage. Plasma concentrations of amitriptyline and nortriptyline vary very widely between individuals and no simple correlation with therapeutic response has been established. Amitriptyline and nortriptyline cross the placenta and are distributed into breast milk. Mecobalamin substances bind to intrinsic factor, a glycoprotein secreted by the gastric mucosa, and are then actively absorbed from the gastrointestinal tract. Absorption is impaired in patients with an absence of intrinsic factor, with a malabsorption syndrome or with disease or abnormality of the gut, or after gastrectomy. Absorption from the gastrointestinal tract can also occur by passive diffusion; little of the vitamin present in food is absorbed in this manner although the process becomes increasingly important with larger amounts such as those used therapeutically. After intranasal dosage, peak plasma concentrations of cyanocobalamin have been reached in 1 to 2 hours. The bioavailability of the intranasal preparation is about 7 to 11% of that by intramuscular injection. Mecobalamin is extensively bound to specific plasma proteins called transcobalamins; transcobalamin II appears to be involved in the rapid transport of the cobalamins to tissues. Mecobalamin is stored in the liver, excreted in the bile, and undergoes extensive enterohepatic recycling; part of a dose is excreted in the urine, most of it in the first 8 hours; urinary excretion, however, accounts for only a small fraction in the reduction of total body stores acquired by dietary means. Mecobalamin diffuses across the placenta and also appears in breast milk. Mechanism of Action Antidepressant effect of Amitriptyline is due to inhibition of reuptake of Serotonin and Norepinephrine by neuronal membranes. Earlier it was believed that the same was responsible for its analgesic action. But now it has been demonstrated due to: – Sodium channel blockade similar to local anaesthetic. – Blockade of Serotonin Receptors - 5-HT2A, 5-HT2C, 5-HT3, 5-HT6 & 5-HT7 – Inhibition of Nicotinic Acetylcholine Receptors Mecobalamin – Enhances synthesis of proteins in nerve cells promotes myelinization axonal regeneration Helps in generation of enzyme methionine synthase - regeneration of methionine from homocysteine. Restores diminished neurotransmitter (Acetylcholine) levels. Other pharmacodynamic properties: Amitriptyline, a tertiary amine tricyclic antidepressant, is structurally related to both the skeletal muscle relaxant cyclobenzaprine and the thioxanthene antipsychotics such as thiothixene. It is extremely sedating, and thus improvement of sleep patterns can be the first benefit of treatment. Amitriptyline exhibits strong anticholinergic activity, cardiovascular effects including orthostatic hypotension, changes in heart rhythm and conduction, and a lowering of the seizure threshold. As with other antidepressants, several weeks of therapy may be required in order to realize the full clinical benefit of amitriptyline. Although not a labelled indication, amitriptyline is widely used in the management of chronic non-malignant pain (e.g., post-herpetic neuralgia, fibromyalgia). Mecobalamin as a coenzyme of methionine synthetase, mecobalamin plays an important role in transmethylation in the synthesis of methionine from homocysteine. Mecobalamin is well transported to nerve cell organelles, and promotes nucleic acid and protein synthesis. Experiments in rats show that mecobalamin is better transported to nerve cell organelles than cyanocobalamin and promotes nucleic acid and protein synthesis more than cobamamide does. Experiments with cells from the brain origin and spinal nerve cells in rats also show mecobalamin to be involved in the synthesis of thymidine from deoxyuridine, promotion of deposited folic acid utilization and metabolism of nucleic acid. It promotes axonal transport and axonal regeneration. It exhibits neuropathologically and electrophysiologically inhibitory effects on nerve degeneration in neuropathies induced by drugs, such as adriamycin, acrylamide, and vincristine (in rats and rabbits), models of axonal degeneration in mice and neuropathies in rats with spontaneous diabetes mellitus. It promotes the synthesis of lecithin which is the main constituent of medullary sheath lipid. It also increases myelination of neurons in rat tissue culture more than cobamamide does. It restores delayed synaptic transmission and diminished neurotransmitters back to normal. Indication: AmNurite tablets are indicated in patients with: Peripheral neuropathies Neuritis Diabetic Neuropathy Spondylitis Chronic Low Back Pain Radiculopathy Trigeminal neuralgia Post Herpetic Neuralgia Contraindication: AmNurite tablets are contraindicated in patients with: Hypersensitivity to any component It should not be given concomitantly with a MAO inhibiting compound. Impaired liver function History of urinary retention – Benign Prostatic Hypertrophy (BPH) Pregnancy and Lactation Drug Interaction: Amitriptyline may block the antihypertensive action of guanethidine or similarly acting compounds. When amitriptyline is given with anticholinergic agents or sympathomimetic drugs, including epinephrine combined with local anesthetics, close supervision and careful adjustment of dosage are required. Since amitriptyline, in combination with anticholinergic type drugs, may give rise to paralytic ileus, particularly in elderly or hospitalized patients, appropriate measures should be taken if constipation occurs in these patients. Cimetidine is reported to reduce hepatic metabolism of certain tricyclic antidepressants. Caution is advised if patients receive large doses of ethchlorvynol concurrently. Transient delirium has been reported in patients who were treated with 1 g of ethchlorvynol and 75 to150 mg of amitriptyline. Amitriptyline may enhance the response to alcohol and the effects of barbiturates and other CNS depressants. Delirium has been reported with concurrent administration of amitriptyline and disulfiram. Hyperpyrexia has been reported when tricyclic antidepressants are administered with anticholinergic agents or with neuroleptic drugs, particularly during hot weather. Decreased GI tract absorption with neomycin, aminosalicylic acid, H2-blockers and colchicine. Reduced serum concentrations with oral contraceptives. Reduced effects in anaemia with parenteral chloramphenicol. Decreased GI tract absorption with neomycin, aminosalicylic acid, H2-blockers and colchicine. Reduced serum concentrations with oral contraceptives. Reduced effects in anaemia with parenteral chloramphenicol Adverse effects: Behavioral: drowsiness, fatigue, activation of latent schizophrenia, disorientation, confusional states, hallucinations, delusions, hypomanic reactions, disturbed concentration, nightmares, insomnia, restlessness, agitation, excitement, jitteriness, anxiety, giddiness. Neurological: epileptiform seizures, coma, dizziness, tremors, numbness, tingling, parasthesias of the extremities, peripheral neuropathy, headache, ataxia, alteration in EEG patterns, extrapyramidal symptoms including abnormal involuntary movements and tardive dyskinesia, dysarthria, tinnitus, incoordination, and slurred speech. Anticholinergic: urinary retention, dilatation of the urinary tract, constipation, paralytic ileus, especially in the elderly, hyperpyrexia, dry mouth, blurred vision, disturbance of accommodation, increased intraocular pressure, precipitation of latent glaucoma, aggravation of existing glaucoma, and mydriasis. Cardiovascular: quinidine-like effect and other non-specific ECG changes and changes in AV conduction, prolonged conduction time, asystole, hypotension, syncope, hypertension, palpitation, arrhythmias, heart block, ventricular tachycardia, fibrillation, myocardial infarction, stroke, unexpected death in patients with cardiovascular disorders. Hematologic: bone marrow depression, including agranulocytosis, leukopenia, eosinophilia, purpura, thrombocytopenia. Allergic: skin rash, urticaria, photosensitization, edema of the face and tongue, itching. Gastrointestinal: nausea, epigastric distress, heartburn, vomiting, hepatitis (including altered liver function and jaundice), anorexia, stomatitis, peculiar taste, diarrhea, parotid swelling, black tongue may occur. Endocrine: testicular swelling, gynecomastia and impotence in the male, breast enlargement and galactorrhea in the female, increased or decreased
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